Chapter 1 of 12 · Case-Based Learning
Introduction
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What the experts said
Patients with acute cholecystitis who are cooled down and discharged have a high recurrence rate and often return on weekends, making management more difficult.
For a 45-year-old patient with straightforward acute cholecystitis and normal liver function tests, early cholecystectomy during the index admission is favored over medical management.
Acute cholecystitis is an obstructive diverticulopathy where the cystic duct becomes obstructed by a stone, causing backup of pressure, decreased blood flow in the wall, wall thickening, and potential rupture.
In patients with significant cardiac history, the risk of taking them to the operating room includes precipitating an acute cardiac event.
Percutaneous cholecystostomy tubes placed by interventional radiology can be very helpful for patients who are not good candidates for operative intervention.
The combination of percutaneous cholecystostomy tubes with antibiotics is very effective in managing acute cholecystitis in sicker patients, with most having an uneventful recovery and being able to leave the hospital.
Before removing a cholecystostomy tube, it is important to wait 4-6 weeks and perform a cholangiogram through the tube to ensure the cystic duct is patent, otherwise recurrent episodes will occur immediately after tube removal.
For patients on antiplatelet therapy due to cardiac stents who need to wait a year, leaving a cholecystostomy tube is reasonable because once they can come off Plavix or aspirin, it is easier to manage a recurrent episode definitively.
Patients with cholecystostomy tubes who later undergo surgery tend to be more challenging cases that need to be planned well and should not be added on at the end of a long surgical day.
The cholecystostomy tube can be useful during surgery for finding anatomy when there are adhesions and for shooting an intraoperative cholangiogram if the surgeon is lost.
Palmer's point is located about two finger breadths below the rib cage on the left side in the midclavicular line and is one of the safest locations for initial trocar placement.
Placing the most lateral trocar while being able to see the gallbladder allows the assistant to grab and elevate it, providing better positioning for the surgeon's left hand.
In acute cholecystitis cases, tissue can be very edematous and bleed easily; controlling bleeding early with cautery is important because uncontrolled bleeding impedes visualization later.
There is a low threshold to decompress tense, hard, thick gallbladders before attempting to grasp them, using a long reusable needle connected to a 60cc syringe inserted at the fundus under direct vision.
In acute cholecystitis, gallbladders tend to have a thicker rind, and once on the gallbladder wall, tissues can be gently and patiently teased down towards the duodenum.
The cystic artery can be visualized as Calot's node is taken down, and dissection should extend up towards the body of the gallbladder to get length, because staying on the gallbladder ensures safety.
Dissection should occur at the junction of the cystic duct and gallbladder, and the cystic artery and gallbladder, not as close to the common duct as possible, because that is how bile duct injuries occur.
The critical view of safety requires visualizing the cystic duct, the gallbladder wall, liver in the dissection window, and the cystic artery within Calot's triangle.
Taking some of the gallbladder just superior to the cystic duct junction and removing the back wall from the liver bed provides increased length for dissection.
Before attempting to cannulate the cystic duct for cholangiography, placing a clip close to the gallbladder and making a dicotomy, then milking the cystic duct proximally with scissors or a Maryland dissector can help extract stones.
Flushing the cystic duct with 20cc of saline before cholangiography helps clear sludge and stones and removes air bubbles from the system.
To get contrast to flow proximally into the liver during cholangiography, techniques include placing the patient in reverse Trendelenburg position or using the camera to compress the distal common bile duct.
For small stones in the distal common bile duct, initial management includes flushing the duct and administering glucagon to relax the ampulla, which can sometimes help pass distal stones.
Commercial transcystic common bile duct exploration kits include a percutaneous introduction catheter with a step dilator, and the key is to place a wire under fluoroscopic guidance distally into the duodenum.
Transcystic exploration kits include a Dormia-type basket for crushing and retrieving stones and a balloon dilator that can push small stones through by performing an antegrade sphincteroplasty.
In difficult acute cholecystitis cases where the infundibulum, cystic duct, artery, and Calot's triangle cannot be defined, a fundus-down approach is used aggressively.
When fundus-down dissection fails to progress, the decision is between opening the gallbladder for partial cholecystectomy or leaving part of the back wall on the liver, rather than risking injury by pursuing the cystic duct in severe inflammation.
Opening the gallbladder, removing all stones, and placing a large tube creates a cholecystostomy that can bail out a horrible case.
Some patients have a very superficial right hepatic ductal system, and digging too deep into the liver during dissection can injure it, causing bile leaks that are often mislabeled as duct of Luschka leaks.
In subtotal cholecystectomy, after opening the gallbladder and removing stones, the remnant is typically closed rather than left open, and a drain is placed to control potential bile leaks.
When leaving the back wall of the gallbladder on the liver in necrotic, falling-apart cases where anatomy near the cystic duct is unclear, the mucosa is cauterized with high coagulation setting and a drain is placed.
The primary goal in difficult cholecystitis cases is avoiding a major bile duct injury, which would be a disaster, even if it means not achieving complete cholecystectomy.
There is no hesitation to add additional trocars as needed during difficult cases, as port number is not magical and they should be placed where needed.